| NPI | 1578827713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 81717) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 2624) |
| Enumeration Date | 2012-07-03 |
| Last Update Date | 2026-04-10 |